Efficacy of short-term versus long-term chest tube drainage following talc slurry pleurodesis in patients with malignant pleural effusions: A randomised trial

Summary

Talc pleurodesis is commonly used in the palliative treatment of malignant pleural effusions but the shortest and most effective regime has not been determined. In particular, it is not clear when the intercostal drain should be removed following the insertion of sclerosant. We conducted a single-centre, randomised, open trial of drain removal at 24 h versus 72 h following talc slurry pleurodesis. The primary outcome measure was success of pleurodesis (no recurrence of effusion on chest radiograph at 1-month follow-up) and secondary outcome measures included length of hospital stay and mortality. We found no difference between recurrence of pleural effusion in those randomised to drain removal at 24 h and those randomised to drain removal at 72 h (p > 0.5). However, length of stay was significantly reduced when the chest drain was removed at 24 h (4 days versus 8 days; p < 0.01). Mortality did not differ between the two groups. We conclude that this shorter pleurodesis regime is safe and effective.

Introduction

Malignant pleural effusions are a common cause of morbidity and admission to hospital. The majority of small malignant effusions will progress and increase in size if not treated and although therapeutic aspiration of fluid or insertion of a chest drain is associated with rapid relief from breathlessness, recurrence rates may be up to 100% after 1 month [1]. Repeated drainage increases the likelihood of fluid forming locules and trapping of the lung preventing re-expansion. The British Thoracic Society therefore recommends early pleurodesis for patients with malignant effusions who are symptomatic with breathlessness from their pleural fluid and have improvement in symptoms with thoracocentesis [1].

Pleurodesis can be performed by ‘medical’ pleurodesis, where an agent is instilled into a chest drain, or by surgery such as video assisted thoracoscopic surgery (VATS). A number of chemical agents have been used to perform medical pleurodesis including bleomycin; tetracycline; doxycycline; Corynebacterium parvum and sterile talc. Sterile talc is currently recommended in the BTS guidelines with success rates averaging 90% (range 88–100%) [1]. Medical pleurodesis is usually performed on in-patients via insertion of an intercostal chest drain and instillation of talc as slurry. Adequate preparation of the pleural space is vital to the success of pleurodesis as residual fluid will reduce the efficacy, but it is not clear how long the drain needs to remain after instillation of talc. As patients with terminal disease and only short expected survival are anxious to avoid long periods of hospitalisation, reducing the length of hospital stay whilst still achieving successful pleurodesis is likely to be of benefit. A previous trial using tetracycline pleurodesis, found that removal of the chest drain after 24 h was as effective as standard protocol drain removal (once drainage less than 150 ml/day) leading to a reduction in hospital stay [2]. No studies have assessed drain removal after talc slurry pleurodesis. This study investigates whether talc is effective in pleurodesis if the drain is removed at 24 h versus 72 h after chemical instillation.